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2 What’s Inside Step One – Realize you are on a journey, not a raceStep Two – You are an important member of your IVF TeamStep Three – IVF is a stressful process – learn some tricks to copeStep Four – Positively, Absolutely, Must DO’s!Step Five – IVF ConsentsStep Six – IVF FinancialsStep Seven – IVF CalendarStep Eight – IVF MedicationsStep Nine – Procedures, all of themStep Ten – Egg Retrieval/ Oocyte Pick upStep Eleven – Waiting and Schedule of CallsStep Twelve – Day of Embryo TransferStep Thirteen – Worries, OHSS, and moreResources

3 Step One – Realize you are on a journey, not a raceIt has taken you both time and heartfelt concern about your fertility to get you to the point of accepting that IVF is your Treatment of ChoiceWonderful, now breathYou will be going though many different feelings and “invasions of privacy” as we test and determine the best course of treatmentTry to understand that our goal, like yours, is an OHBOne Healthy Baby … so yes, it is worth itThere WILL BE CHANGES as you go alongWe Personalize your care… no cookie cutter, so your biology will dictate the treatmentsBe FlexibleWe do NOT expect you to be an expert! Ever!So call us, ask questions, do not leave until you understand the steps, BUT, do the steps, do NOT try to “game” how we do thingsThis will INTERFERE with you work, your play, your family, your friends, your free time, your plansJohn Lennon quips, “Life is what happens between plans…” embrace the chaos!

4 Step Two – You are an important member of your IVF TeamYou are the KEY member of the IVF TeamYou must READ everything we give youYou must understand and ask questions if you do notYou must Follow the Plan…even as it variesYou must set alarms to take your meds, visitsYou recommend at least two or three alarms per eventTiming is EverythingYou must understand the consents, BEFORE you sign themYou must track your medicationsDo you have enough?Do you need more?How many more days do you need your meds?Is it the weekend…do you have refills?Call with your period, first day!Why?The call helps us coordinate your testing, your care plan, your treatments, lets us check to ensure that you are in-sync!Your PARTNER has tasks and duties too!If male, need sperm and bloodworkIf female, need bloodworkEither male or female MUST SIGN CONSENTS

5 Step Three – IVF is a stressful process – learn some tricks to copeThey have called the IVF process an “emotional rollercoaster”It definitely is for two reasonsYou are “out of control” or at least that is what it feels likeYou are in an hormonal soup!Estrogen keeps women able to cope with stress by cryingCrying cleans the tear ducts… we have plenty of KleenexWalks, simply walking outside for 20 min each day can and will relieve stressYes you can make the timeAcupuncture or TCMWe have done many years of study that demonstrate the TCM in the form of acupuncture can increase your odds of an OHB (One Healthy Baby) but it has been demonstrated repeatedly that it can reduce stressTalk and talk and talk to your friends, family, partner and us… it is OK… we know it is different and strange, just remember we have been doing this for years and we probably heard you concerns a hundred times… we can help… ask.

6 Step Four – Positively, Absolutely, Must DO’s!Call with your period EACH and EVERY month until you are pregnant! ReallyThis keeps us all in the know!Mark your calendar four weeks after your first day of bleeding with your menses, then the next four, etc.Critical for TestingCritical for TreatmentsCritical for keeping you progressing to your OHBCritical for us to monitor the risks for Ectopic pregnanciesCritical for our PCOS patients, CALL WHEN you THINK you should have your period… every 28 SDAYS… mark your calendarCONSENTSMust be complete and YOU must confirm receipt by a member of my teamSPERMWe must have fresh or frozen ON SITE… it doesn’t help if the sperm are in another state and your eggs are in Colorado Springs!PAYMENTSYour payments allow us to get the supplies we need, the equipment kept at optimal functioning, the staff happy and our lights on… please put on your calendar when your payments are due… we will try to remind you, but honestly, it is your responsibility to keep track of all required dates for treatments and payments.TELL US if you missed, or did a medication mistake, or will be out of town, or are running out of medications, or can’t make appointments, or having issues with your drugs, timing, cash flow, injections, or simply are confused…We have a 24 hour phone line, and Dr. Mag’s cell phone is …call it if something urgent comes up… he is happy to helpMUST take the meds how we prescribe it… do not vary in our protocols and even if you do or did, TELL US

7 Step Five – IVF ConsentsFor treatmentsFor medicationsFor proceduresFor IVFFor Trial TransfersFor Embryo TransfersFor Selective Reduction of EmbryosFor SurgeryFor number of embryos to transferFor use of Donor eggs if applicableFor use of Gestational Carrier if applicableFor saving Frozen Eggs, if applicableFor Efficiency Cycles, to use only 6 eggs from a Donor if applicableFor getting your OLD RECORDSFor allowing us to share your information with other doctors or your partner

8 Step Six – IVF FinancialsFinancials are simple and straight forwardPremier IVF at RMFC is $ 4,800Includes everything except medicationsMedications run between $ 1500 to $ 3600Yes we will put in applications to help you pay for your medsNo promises, it is based on YOUR incomeHQA-IVF with monitoring in your city$ 4,800 for RMFCUltrasounds and Bloodwork at YOUR city vary between $ 800 to $ 2200We have NOT control of what your doctor charges but will help if we can to find alternativesIn Las Cruces, Mountain View will do the monitoring for $ 800In ABQ, UNM will do the monitoring for $ 2200These are only examplesWe charge $ 500 for Ultrasound and Blood work at RMFCWe do NOT charge for your Frozen Embryo Transfers any of the typical “technical” fees of $ 3000 to $ 5000This applies to a Failed Fresh cycle with Frozen embryos that are not used in the Fresh CycleIf you want to add Comprehensive Chromosomal Screening (CCS) to an RMFC IVF Cycle, then the fee is $3,200 for 8 embryos, more if there are more embryosSo you can add this to one cycle, so $ 4,000 + $ 3,200 = $ 8,000If two Fresh cycle and one CCS = $ 7, ,200 = 11,000If three Fresh cycles and one CCS = $ 10,800 + n3,200 = $ 14,000Remember medications are in addition to these costsAlso, if you do not get pregnant with Fresh transfer, a Frozen transfer is only the RMFC cost of $ 500 for ultrasounds and bloodworkAll payments must be confirmed 4 weeks prior to your IVF cycle… no exceptions, sorry.Deb is your contact

9 Step Seven – IVF CalendarYour IVF Calendar of TreatmentsWhat it is:A GUIDE to your care based on the “average’ response of an IVF patient to her medicationIf is NOT an ABSOLUTE guide… it can and may vary based on your responsesWhat it is NOT:An ABSOLUTE guide to dates and times of your visit… you can and may vary based on your biology… I already said that How to use itTell your employer that you need time offDay of egg retrieval PLUS the next dayDay of Embryo transfer PLUS the next 4 daysDo not go OUT OF TOWNFor days during your stimulation with fertility medications, you will need to be able to get an ultrasound, bloodwork, trial transfer, physical exam, emergency medications if you did NOT keep track, additional medications as Dr. Mag orders, follow up etc…So Plan to be IN TOWN during your 30 days of care… please!

10 Step Eight – IVF MedicationsWhat they AreLupron – keeps you from losing the wonderful eggs your growing in your folliclesThis medication (some will be on Ganirelix, see below) is THE most critical medicationYou miss your dose… YOU LOSE your eggs, simple.Do NOT miss any doses, call us if you are unsure at allGanirelix – keeps you form losing the eggs you are growing in your follicles, like Lupron, see aboveDo not worry about which medication, Lupron or Ganirelix, that you are onFor some of you : YOU MAY BE ON BOTH!!Follistim Gonal F, Bravelle – this are your follicle stimulation medications, they help you grow the follicles that will give us our eggsYour doses and timing are IMPORTANTWrite down what you take each and every daySee next page for Log sheetCalculate your doses and calculate how many days worth of medications you have and TELL us at each visit what you have leftEspecially if the weekend or holidays are coming upWe do have an emergency supply but DO NOT count on itMenopureDr. Magarelli sometimes uses a “missed protocol” that means he has you take Menopure for your evening dose instead of the F, GF or B aboveThis are usually and almost ALWAYS Intramuscular with a 1.5 inch needleBe sure you know which needles go with which medicationsAskWe also can direct you to websites for instructions????Miscellaneous medicationsDoxycycline (if NOT allergic) for both partners starting usually at Stim StartMedrol and anti-inflammatory medication usually startedPre natal vitamins, extra folic acid, baby aspirinMen, Mega Man VitaminsAnti-nausea medications on day of egg retrievalPain medications on day of retrieval and thereafter as needed, no worries if you need more… rare, but do not hesitate to ask

14 Step Ten – Egg Retrieval/ Oocyte Pick up (OPU)The Egg Retrieval is usually scheduled after 11 days of fertility medicationsOn Day 11 of fertility medications or there abouts, you will be told EXACTLY what time to take your “trigger shot” or HCGThis shot is usually in the very late evening, and/or early morning hours 1am or soSet THREE alarms… timing is CRITICALThe dose is usually 5000 to 10,000IU and is given either intramuscularly or sub cutaneousYou WILL be told… ASK if uncertain, then ASK again34 to 36 hours later, usually 35 hours later, we will take the eggs out via a vaginal procedure… see Step NineYou will be asleep with a CRNA at your side giving anesthesia medications… do NOT eat after midnight on the day before your egg retrievalThat day and the next day you RESTWe will tell you the Number of Eggs retrievedWE will then fertilize the eggs using a procedure called ICSISee Step Nine – Procedures continuedMust have someone drive you, NOT A TAXI!

15 Step Eleven – Waiting and Schedule of CallsWaiting and Scheduling of CallsWe KNOW you are nervous about your eggs, embryos and future babies… we KNOWWe will call you at the end of each day, usually between 4 and 6pmIf no call… call us or if the nurse does not get back to you within 2 hours, then call Dr. MagMy staff MUST get approval for prescriptions, etc. and we will have them usually within 24 hours of your call, not before… so please plan ahead! (not the same day… sorry)If Dr. Mag calls, usually it means that there is a medical decision to be made… do NOT panic… he is doing his job!Your Ultrasounds and Clinic AppointmentsUltrasounds at RMFC are usually done between the hours of 7am and 10 amBe sure to be there 5 min before, it will get busyBe sure you know when your NEXT appointment isDo NOT leave the clinic until you know…this is Critical for your stimulation and other proceduresIf unsure ASK, then ASK againLabs and Embryo Reports can take us late into the afternoon and early evening to reportDo NOT worry, see aboveIf you are being monitored in a clinic other than RMFC, we are at the mercy of that team… so PLEASE reinforce to your care provider how important it is to SEND the results to RMFC is fax, andDo NOT worry, Dr. Mag has been doing this for many years and can help mitigate late results, one day matters, but we are able to offset lack of data with clinical experienceHowever, please, again, tell you providers to send the info… it is that important!

16 Step Twelve – Day of Embryo TransferEmbryo Transfer Day – Wow – what a trip!Our goal is to safely transfer your future baby or babiesOur goal is OHB, One Healthy Baby, really, one is what you wantWe know Twins are cute, but they do have issues with survival and safety and future growth, so please have as your goal an OHBLikely you will receive one (1) embryo and possibly two (2) during the transfer… yes we check your name multiple times to ensure it is YOU and YOUR embryo!We use an abdominal ultrasound to monitor the progress of the embryo transferHAVE a FULL and slightly UNCOMFORTABLE bladder!It really helpsEven if requested by accident by a new MA, please do NOT pee when you get to RMFC… FULL BLADDER is what we need unless you are told otherwiseYour Partner and Mom or best friend CAN be in the room for the embryo transfer… we love it!You CAN NOT drive after the transfer… we will be giving you valium… so no impaired driving…Bring Water for both pre/post transfer to drinkBe sure to schedule your Pre/Post Acupuncture treatments… we really recommend it!

17 Lab & Other StuffOur Laboratory team is dedicated to managing your sperm, your serum for hormones, your eggs, your embryosThe INSIST on accuracy, precision and RIGHT person, RIGHT test, RIGHT timeSo, be sure you and YOUR PARTNER have a valid IDDrivers licensePLUS insurance cardsYou MUST have a photo taken of you and your partner which is placed in our Electronic Medical RecordWhy? You want your sperm, your eggs, your embryosWe are certified by CAP, CDC, FDA, AAS organizations to ensure safe and accurate laboratory measurements and techniques

18 Step Thirteen – Worries, OHSS, and moreWhat if I do not respond to the medications?We will adjust the dose, but if you truly are NOT responding you will have a discussion with Dr. MagWhat if we miss taking our Lupron?NOT a good idea, so CALL immediately, we may be able to rescue your cycleWhat if things are going TOO WELL, i.e., Ovarian Hyper stimulation (OHSS) is starting?We will ask you to start consuming VAST amounts of protein, over 150 grams additional per dayWe will ask you to contact an Acupuncturist , ABORM certified, to help manage your OHSS…real importantWe will INSIST that you measure your weight each and every dayWe will INSIST that you contact us if you notice more than 1 pound of weight gainWe will INSIST that you TRACK all your protein consumptionWe will INSIST you take frequent breaks from standing and reclineWe will INSIST that you consume lots of fluids, especially some with electrolytes like bouillon, Gatorade, Recharge, etc.What if our embryos do NOT grow?This rarely happens, usually it is because the embryo, in nature’s wisdom, is not growing normally… Dr. Mag will discuss this with you, but likely no embryo transferWhat if we run out of medications?This really should NOT happen, see Step Two, but if you do, be SURE to tell us… we usually have a stash of meds…What if we do not get a call back?If you have waited until 6pm or so and no call back… CALL Us or if urgent Dr. magWorse case, take the same amount of Lupron or Ganirelix and your stimulation medications like Gonal F, Follistim, or Bravelle or Menopure